Quick Answer

Tracheostomy patients presenting to the ED require systematic assessment and immediate action for airway emergencies. The most critical emergencies are:

1. Blocked/obstructed tube - Remove inner cannula, attempt suction, replace tube if blocked
2. Accidental decannulation - Fresh stoma (< 7 days): Cover stoma, ventilate via mouth/nose, call ENT; Mature stoma (> 7 days): Reinsert tube or smaller size
3. Major bleeding - Suspect tracheoinnominate artery fistula (TIF) if massive arterial bleed: Hyperinflate cuff, apply digital pressure (Utley maneuver), immediate surgical intervention
4. Tracheal stenosis - Progressive dyspnoea on exertion, stridor, often presents months to years after tracheostomy

ED Assessment Approach: Follow the SOS mnemonic:

• Suction - Can you pass a suction catheter?
• Obstruction - Is the tube blocked?
• Situation - Fresh stoma (< 7 days) vs mature stoma (> 7 days)?

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ACEM Exam Focus

Fellowship Written Examination

Common SAQ Themes:

1. Emergency management of blocked tracheostomy
2. Recognition and management of tracheoinnominate artery fistula
3. Approach to accidental decannulation
4. Decannulation assessment and protocols
5. Post-tracheostomy complications (early vs late)
6. Tracheal stenosis investigation and management

Examiners Expect:

• Clear systematic approach to tracheostomy emergencies
• Understanding of timing-based differences (fresh vs mature stoma)
• Knowledge of life-threatening complications requiring surgical intervention
• Appropriate escalation pathways (ENT/Anaesthesia/ICU)
• Recognition of when NOT to intervene (fresh stoma decannulation)

Fellowship OSCE

Potential Stations:

• Tracheostomy emergency management (blocked tube, dislodgement, bleeding)
• Assessment of a patient with a tracheostomy in respiratory distress
• Communication with carer/family about tracheostomy complications
• Practical skills: Changing tracheostomy tube, suctioning, cuff management

Marking Domains:

• Systematic assessment (SOS approach)
• Correct sequence of interventions
• Communication with patient and team
• Recognition of red flags requiring immediate escalation

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Key Points

1. Always attempt suction first - If catheter passes, tube is patent; if it fails, tube is obstructed or displaced
2. Fresh stoma (< 7 days) - Tract not matured; DO NOT attempt blind reinsertion; cover stoma and ventilate via mouth/nose
3. Mature stoma (> 7 days) - Attempt reinsertion of same-size tube; if unsuccessful, try one size smaller
4. Tracheoinnominate artery fistula - Mortality > 50%; massive arterial bleed is a surgical emergency; hyperinflate cuff and apply digital pressure
5. Cuff pressure monitoring - Maintain < 25 cm H2O to prevent mucosal ischemia and tracheal stenosis
6. Bedside emergency kit - Must include: spare tube (same and smaller size), obturator, suction catheters, water-soluble lubricant, tracheal dilators, ambu bag
7. Decannulation protocol - Progressive downsizing, cuff deflation trials, capping trials, objective assessment of cough strength, swallowing, and secretions

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Clinical Overview

Epidemiology

Tracheostomy is commonly performed in critically ill patients requiring prolonged mechanical ventilation. In Australia and New Zealand, approximately 4-10% of ICU admissions undergo tracheostomy. The rate has increased over the past decade due to improved survival of patients with complex medical conditions.

Incidence and Prevalence:

• ICU tracheostomy rate: 4-10% of ICU patients
• Prolonged ventilation > 7-10 days is the most common indication
• Percutaneous dilational tracheostomy (PDT) is now more common than open surgical tracheostomy (OST) in many Australian centres
• Community-dwelling patients with tracheostomy: Increasing due to earlier discharge to home care

Mortality:

• Procedure-related mortality: 0.5-2%
• Tracheoinnominate artery fistula mortality: > 50% despite surgical intervention
• Overall mortality in tracheostomised ICU patients: 20-40% (reflects underlying critical illness, not procedure)
• Post-decannulation mortality: Low (< 1%) in appropriate candidates

Timing of Complications:

• Early complications (< 7 days): 15-30% (bleeding, pneumothorax, tube dislodgement, stomal infection)
• Late complications (> 7 days): 10-40% (tracheal stenosis, granulation tissue, tracheomalacia, tracheoesophageal fistula)

Pathophysiology

Tracheostomy Types

Complications by Timing

Early Complications (Intraoperative to < 7 days)

Haemorrhage:

• Minor bleeding (5-10%): Local ooze from anterior jugular veins or thyroid isthmus
• Major bleeding (1-2%): Injury to major vessels (thyroid ima, brachiocephalic, innominate)
• Management: Direct pressure, topical haemostatic agents, surgical exploration if > 50 mL fresh blood

Pneumothorax/Pneumomediastinum:

• Incidence: < 1%
• Mechanism: Direct pleural injury (low tracheostomy) or high ventilatory pressures
• More common in paediatric patients and those with COPD (barotrauma)
• Requires chest drain insertion

Subcutaneous Emphysema:

• Incidence: 1-2%
• Caused by tight skin closure or tube malpositioning
• Usually self-limiting; may require loosening of sutures

Tube Dislodgement:

• Incidence: 1-2%
• Fresh stoma (< 7 days): Tract not epithelialised - surgical emergency
• Mature stoma (> 7 days): Tract matured - can attempt reinsertion

Stomal Infection:

• Incidence: 5-10%
• Local cellulitis managed with antibiotics
• May require tube change if persistent

False Tract:

• Risk highest during first tube change before tract matured
• Caused by blind reinsertion in fresh stoma

Late Complications (> 7 days to years)

Tracheal Stenosis:

• Incidence: 1-5%
• Stoma-level stenosis: From oversized fenestration, chondritis, infection
• Cuff-level stenosis: From prolonged cuff inflation, high cuff pressure (> 25 cm H2O)
• Usually presents months to years after tracheostomy
• Symptoms: Progressive dyspnoea on exertion, inspiratory stridor, difficulty weaning

Tracheomalacia:

• Weakening of tracheal cartilage leading to airway collapse on expiration
• Incidence: < 1%
• May require stenting or surgical reconstruction

Tracheoinnominate Artery Fistula (TIF):

• Incidence: < 0.7%
• Occurs typically 3-4 weeks post-tracheostomy
• Mechanism: Pressure necrosis from tube tip or cuff against innominate artery
• Sentinel bleed: Small warning bleed occurring hours to days before massive haemorrhage
• Mortality: > 50% despite emergency surgery

Tracheoesophageal Fistula (TEF):

• Incidence: < 1%
• Pressure necrosis between posterior tracheal wall and anterior esophageal wall
• Presents with recurrent aspiration, coughing with oral intake

Granulation Tissue:

• Incidence: 10-40%
• Forms at stoma site or distal tip of tube
• Causes bleeding, airway obstruction
• Managed with silver nitrate cautery, laser excision, or tube change

Persistent Stoma:

• Failure of tracheostomy site to close after decannulation
• More common with long-term cannulation (> 6 months)
• May require surgical closure

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Clinical Approach

Initial Assessment

Primary Survey (ABCDE)

Airway:

• LOOK at patient: Are they in respiratory distress? Cyanosis? Use of accessory muscles?
• LISTEN at mouth AND tracheostomy site: Is there airflow? Stridor? Wheeze? Gurgling?
• FEEL for airflow: Place hand over stoma and mouth separately

Call for help immediately if patient appears compromised.

Critical First Steps (performed simultaneously):

1. Apply high-flow oxygen to both mouth/nose AND tracheostomy site
2. Check ventilation: Is chest rising? Are breath sounds equal?
3. Attempt to pass suction catheter through tracheostomy tube

SOS Approach

S - SUCTION: Can a suction catheter pass?
    YES → Tube likely patent, continue assessment
    NO → Tube obstructed or displaced

O - OBSTRUCTION: What type of obstruction?
    Inner cannula blocked → Remove inner cannula
    Mucus plug → Suction thoroughly
    Blood clot → May need tube change

S - SITUATION: Timing of tracheostomy?
    Fresh stoma (< 7 days) → Surgical emergency (do NOT replace blindly)
    Mature stoma (> 7 days) → Attempt tube replacement

Tube Assessment

Step 1: Remove Inner Cannula

• Most tracheostomy tubes have a removable inner cannula
• Many obstructions are confined to inner cannula only
• Remove and replace with clean inner cannula
• If patient improves, obstruction was in inner cannula

Step 2: Attempt Suction

• Pass suction catheter through tube
• If catheter passes freely → tube is patent
• If catheter cannot pass → tube is obstructed or displaced

Step 3: Check Cuff (if applicable)

• Deflate cuff to allow airflow around tube to upper airway
• May improve ventilation if tube is partially obstructed
• Use 10 mL syringe attached to pilot balloon

Step 4: Assess for Displacement

• Look for distance markings on tube
• Tube should be inserted to appropriate depth (usually 2-3 cm beyond stoma)
• Excessive tube movement suggests displacement

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Management

Emergency Management Algorithms

Algorithm 1: Blocked/Obstructed Tube

PATIENT IN DISTRESS WITH TRACHEOSTOMY

│
├─ CALL FOR HELP
│   └─ Activate emergency response team / difficult airway cart
│
├─ OXYGEN
│   ├─ Apply high-flow oxygen to mouth/nose AND tracheostomy site
│   └─ Use non-rebreather mask (15 L/min) at both sites
│
├─ REMOVE INNER CANNULA (if present)
│   ├─ Remove immediately
│   └─ Replace with clean inner cannula
│       └─ If patient improves → Obstruction was in inner cannula
│
├─ ATTEMPT SUCTION
│   ├─ Pass suction catheter (size = half internal diameter of tube)
│   │   ├─ If catheter passes freely → Tube is patent
│   │   └─ If catheter cannot pass → Tube is obstructed or displaced
│   │
│   └─ Suction thoroughly (10-15 seconds per pass, repeat as needed)
│       └─ Use sterile technique
│
├─ ASSESS SITUATION
│   ├─ Fresh stoma (< 7 days post-op)?
│   │   └─ Mature stoma (> 7 days post-op)?
│   │
│   └─ If tube still blocked after suction:
│       ├─ Fresh stoma: DO NOT replace blindly
│       │   ├─ Cover stoma with gauze
│       │   ├─ Ventilate via mouth/nose (BVM or tracheal tube)
│       │   └─ Call for ENT/Surgical emergency
│       │
│       └─ Mature stoma: Attempt tube replacement
│           ├─ Remove entire tracheostomy tube
│           ├─ Insert new tube of same size (with obturator)
│           └─ If unsuccessful, try one size smaller
│
└─ CONTINUOUS MONITORING
    ├─ SpO2, respiratory rate, work of breathing
    ├─ Colour, consciousness level
    └─ Prepare for definitive airway (orotracheal intubation)

Algorithm 2: Accidental Decannulation

TUBE DISLODGED FROM TRACHEOSTOMY

│
├─ ASSESS TIMING OF TRACHEOSTOMY
│   ├─ Fresh stoma (< 7 days post-op)?
│   └─ Mature stoma (> 7 days post-op)?
│
├─ FRESH STOMA (< 7 days)
│   ├─ DO NOT attempt blind reinsertion
│   ├─ Cover stoma with gauze/dressing
│   ├─ Ventilate via mouth/nose:
│   │   ├─ Bag-valve-mask ventilation
│   │   └─ Orotracheal intubation if needed
│   ├─ Provide oxygen to stoma while covering
│   └─ Call for emergency ENT/Surgical airway
│       └─ Tract not matured - risk of creating false passage
│
├─ MATURE STOMA (> 7 days)
│   ├─ Check patient's breathing status
│   │   ├─ If breathing comfortably → Continue assessment
│   │   └─ If in distress → Immediate action needed
│   │
│   ├─ ATTEMPT TUBE REPLACEMENT
│   │   ├─ Have spare tube ready (same size and one size smaller)
│   │   ├─ Use water-soluble lubricant
│   │   ├─ Insert obturator into new tube
│   │   ├─ Insert tube through stoma
│   │   │   └─ Aim caudally (towards feet) at 45° angle
│   │   ├─ Remove obturator immediately once tube is in
│   │   ├─ Inflate cuff (if applicable)
│   │   └─ Confirm tube position:
│   │       ├─ Chest rise with ventilation
│   │       ├─ Bilateral breath sounds
│   │       ├─ CO2 detection
│   │       └─ Check distance markings
│   │
│   └─ IF REPLACEMENT UNUCCESSFUL:
│       ├─ Try one size smaller tube
│       ├─ If still unsuccessful → Ventilate via mouth/nose
│       ├─ Cover stoma with gauze
│       └─ Call for ENT/Anaesthesia assistance
│
└─ POST-PROCEDURE
    ├─ Secure tube with appropriate ties/holder
    ├─ Suction if needed
    ├─ CXR to confirm position (if ventilated)
    └─ Document event in notes

Algorithm 3: Major Bleeding from Tracheostomy

BLEEDING FROM TRACHEOSTOMY SITE

│
├─ ASSESS BLEEDING
│   ├─ Minor ooze (< 50 mL total)?
│   └─ Massive arterial bleeding (> 50 mL, pulsatile)?
│
├─ MINOR BLEEDING
│   ├─ Direct pressure with gauze
│   ├─ Check tube position (may be causing trauma)
│   ├─ Suction to clear airway
│   ├─ Observe for progression
│   └─ Consider ENT review if persistent
│
└─ MASSIVE ARTERIAL BLEEDING
    │
    └─ SUSPECT TRACHEOINNOMINATE ARTERY FISTULA (TIF)
        │
        ├─ LIFE-THREATENING EMERGENCY
        │
        ├─ IMMEDIATE ACTIONS:
        │   ├─ CALL FOR HELP
        │   │   ├─ Emergency response team
        │   │   ├─ ENT surgeon (urgently)
        │   │   └─ Prepare for transfer to OR
        │   │
        │   ├─ HYPERINFLATE CUFF
        │   │   ├─ Inflate cuff to maximum volume (30-40 mL air)
        │   │   └─ This compresses innominate artery against sternum
        │   │
        │   ├─ DIGITAL COMPRESSION (Utley Maneuver)
        │   │   ├─ Insert finger into stoma
        │   │   └─ Apply firm anterior pressure against manubrium
        │   │       └─ Direct compression of innominate artery
        │   │
        │   ├─ PATIENT POSITIONING
        │   │   └─ Neck hyperextended (if not contraindicated)
        │   │
        │   ├─ FLUID RESUSCITATION
        │   │   ├─ Large-bore IV access (two 14G or 16G)
        │   │   ├─ Cross-match blood (O-negative if urgent)
        │   │   └─ Activate massive transfusion protocol if indicated
        │   │
        │   └─ OXYGENATION
        │       ├─ High-flow oxygen to mouth/nose AND stoma
        │       └─ Prepare for definitive airway
        │
        └─ DEFINITIVE MANAGEMENT:
            ├─ IMMEDIATE TRANSFER TO OPERATING THEATRE
            ├─ SURGICAL INTERVENTION:
            │   ├─ Median sternotomy
            │   ├─ Ligation or repair of innominate artery
            │   ├─ May require graft interposition
            │   └─ Tracheal repair
            │
            └─ POST-OPERATIVE:
                ├─ ICU admission
                ├─ Monitor for re-bleeding
                └─ Consider alternative airway (tracheostomy at different level)

Postoperative Care

Immediate Postoperative Period (Day 0-7)

Stoma Care:

• Clean stoma site with saline or 0.9% sodium chloride
• Use sterile technique for dressing changes
• Gauze dressing under tube flange to absorb secretions
• Change dressing when soiled or at least twice daily
• Observe for signs of infection (redness, swelling, purulent discharge)

Tube Securement:

• Use appropriate tracheostomy ties or holder
• Ensure two fingers can fit between ties and neck
• Check tie tension regularly (neck swelling may occur)
• Change ties if soiled or loose

Suctioning:

• Indications: Visible secretions, audible gurgling, increased work of breathing, desaturation
• Technique:
  1. Hyperoxygenate before suctioning
  2. Use sterile catheter (size = half internal diameter of tube)
  3. Insert catheter without suction until resistance met or patient coughs
  4. Apply suction while withdrawing catheter (10-15 seconds)
  5. Rotate catheter during withdrawal to remove secretions from all sides
• Repeat until airway clear, limiting to 3-4 passes maximum
• Monitor SpO2 and patient tolerance

Humidification:

• Essential for patients with tracheostomy (bypasses upper airway)
• Use heated humidifier for ventilated patients
• Use heat and moisture exchanger (HME) for spontaneously breathing patients
• Encourage fluid intake (if oral intake permitted)

Cuff Management:

• Maintain cuff pressure below 25 cm H2O
• Use cuff manometer for accurate measurement
• High cuff pressure causes mucosal ischemia → tracheal stenosis
• Periodic cuff deflation may be attempted during weaning

Tube Changes

First Tube Change:

• Typically performed at 7 days post-tracheostomy
• Delayed if stomal infection, excessive bleeding, or poor wound healing
• Should be done by experienced clinician (ENT or ICU)
• Have appropriate equipment and smaller tube available

Routine Tube Changes:

• Every 4-8 weeks for long-term tracheostomies
• Inspect stoma and trachea during change
• Consider downsizing during weaning process

Equipment Needed:

• Spare tracheostomy tube (same size)
• Spare tracheostomy tube (one size smaller)
• Obturator
• Water-soluble lubricant
• Suction equipment
• Tracheal dilators (if available)
• Dressing materials
• 10 mL syringe (for cuff inflation)
• Appropriate ties/holder

Decannulation Protocol

Decannulation should be a planned, gradual process following objective assessment criteria.

Assessment for Decannulation

Essential Pre-requisites:

• Medical condition stable or improving
• Adequate cough strength (peak cough flow > 160 L/min)
• Effective airway clearance
• Able to manage secretions independently
• Swallowing assessment safe (no significant aspiration risk)
• Consciousness level adequate (RASS > -2, or equivalent)
• No requirement for mechanical ventilation for > 24 hours

Assessment Tests:

1. Cuff deflation trial: Deflate cuff, observe for 24 hours

   • Patient should maintain adequate ventilation without cuff
   • Monitor for increased work of breathing or secretions

2. Capping trial: Place tracheostomy cap (if tube allows)

   • Patient breathes through upper airway
   • Monitor for 24-48 hours for respiratory compromise
   • Remove cap immediately if distress occurs

3. Progressive downsizing:

   • Change to smaller tube sequentially
   • Ultimately may change to uncuffed tube
   • Allows assessment of airway patency through natural passage

4. Swallowing assessment:

   • Bedside swallowing test or formal videofluoroscopy
   • Assess for aspiration risk
   • May require speech pathology review

Decannulation Procedure

Day of Decannulation:

1. Ensure patient and carers are confident with decannulation
2. Perform final cuff deflation trial (if cuffed tube)
3. Have tracheostomy tube available for emergency replacement
4. Remove tube smoothly
5. Cover stoma with dry sterile dressing
6. Patient should breathe through mouth/nose naturally

Post-Decannulation Care:

• Change dressing over stoma site daily
• Stoma will gradually close over 1-2 weeks
• Encourage patient to cough and clear secretions effectively
• Monitor for respiratory distress
• Report any stridor or increased work of breathing

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Investigations

Bedside Assessment

Airway Assessment

Inspection:

• Stoma site appearance (infection, granulation tissue, bleeding)
• Tube position (depth, securement, type/size)
• Respiratory effort (use of accessory muscles, chest movement)
• Skin colour (cyanosis, pallor)

Auscultation:

• Listen at tracheostomy site for airflow
• Listen bilaterally for breath sounds
• Stridor suggests upper airway obstruction
• Wheeze suggests lower airway obstruction

Palpation:

• Feel for airflow at tracheostomy and mouth separately
• Check cuff inflation (if applicable)
• Assess for subcutaneous emphysema

Cuff Pressure Monitoring:

• Use cuff manometer
• Target: < 25 cm H2O
• Check at least once per shift in ICU
• Check daily for community patients

Tube Patency

Suction Test:

• Pass suction catheter through tube
• Should pass freely without resistance
• Note any resistance or point of obstruction

Cuff Leak Test:

• For patients on mechanical ventilation
• Deflate cuff briefly
• Listen for air leak around tube
• Significant leak may indicate tube too small or tracheal dilation

Imaging

Chest X-ray

Indications:

• Following tracheostomy insertion or tube change
• Suspected tube malposition
• Post-decannulation respiratory distress
• Suspected pneumothorax or pneumomediastinum

Findings:

• Confirm appropriate tube depth
• Rule out pneumothorax
• Assess for lung pathology

CT Scan

Indications:

• Suspected tracheal stenosis
• Assessment of tracheal anatomy prior to reconstruction
• Evaluation of tracheoesophageal fistula

Findings:

• Identify level and degree of stenosis
• Assess airway dimensions
• Plan surgical intervention

Bronchoscopy (Flexible or Rigid)

Indications:

• Evaluation of suspected tracheal stenosis
• Removal of granulation tissue
• Assessment of tracheomalacia
• Evaluation of tracheoesophageal fistula

Findings:

• Direct visualisation of airway
• Assessment of mucosal integrity
• Therapeutic interventions possible

Blood Tests

Routine:

• FBC (check for anaemia, infection)
• Coagulation profile (if bleeding or planned procedures)
• CRP/ESR (if infection suspected)

Specific:

• Blood gas (if respiratory compromise)
• Blood cultures (if sepsis suspected)
• Cross-match (if major bleeding or surgical intervention planned)

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Disposition

Admission Criteria

Admit for observation and management if:

Airway-Related:

• Inability to pass suction catheter (obstructed tube)
• Accidental decannulation of fresh stoma (< 7 days)
• Major bleeding from tracheostomy site (> 50 mL)
• Respiratory distress requiring intervention
• Suspected tracheoinnominate artery fistula

Infection-Related:

• Stomal infection with systemic features (fever, cellulitis spreading)
• Tracheitis or bronchitis requiring IV antibiotics
• Suspected aspiration pneumonia

Complication-Related:

• Suspected tracheal stenosis requiring investigation
• Tracheoesophageal fistula
• Tracheomalacia with respiratory compromise

Safe Discharge Criteria

Patient must meet:

1. Stable airway with functioning tracheostomy
2. Patient and carers competent in tracheostomy care:
   • Suctioning technique
   • Tube changing (if appropriate)
   • Emergency management
   • Humidification and care
3. Appropriate equipment available:
   • Spare tubes (same size and one smaller)
   • Suction equipment
   • Humidification device
   • Emergency supplies
4. Follow-up arranged:
   • ENT or respiratory review
   • Community nursing support if needed
5. Education completed:
   • Written emergency plan provided
   • 24-hour contact number for concerns

Special Circumstances:

• Patients requiring ongoing ventilation: ICU or high-dependency unit
• Decannulation candidates: May discharge once decannulated and stable
• Palliative care: May be discharged with community support and symptom management plan

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Complications and Troubleshooting

Early Complications (< 7 days)

Bleeding

Minor Bleeding (< 50 mL):

• Assessment: Stoma site inspection, check tube position
• Management:
  • Direct pressure with gauze for 5-10 minutes
  • Check cuff pressure (reduce if > 25 cm H2O)
  • Suction to clear airway
  • Monitor for progression
• Escalation: ENT review if bleeding persists > 30 minutes

Major Bleeding (> 50 mL):

• Immediate: Suspect tracheoinnominate artery fistula until proven otherwise
• Management: See TIF algorithm above
• Disposition: Urgent ENT review, possible surgical intervention

Pneumothorax

Presentation:

• Sudden respiratory deterioration
• Unilateral decreased breath sounds
• Hyperresonance on affected side

Management:

• 100% oxygen
• Needle decompression if tension pneumothorax
• Chest drain insertion
• CXR confirmation

Subcutaneous Emphysema

Presentation:

• Neck and facial swelling
• Crepitus on palpation

Management:

• Usually self-limiting
• Loosen sutures if tight
• Monitor for progression
• Consider stopping mechanical ventilation temporarily

Tube Dislodgement

Fresh Stoma (< 7 days):

• DO NOT attempt blind reinsertion
• Cover stoma with gauze
• Ventilate via mouth/nose (BVM or orotracheal intubation)
• Urgent ENT/Surgical airway

Mature Stoma (> 7 days):

• Attempt tube replacement (same size, then smaller)
• If unsuccessful, ventilate via mouth/nose
• Urgent ENT/Anaesthesia review

False Tract Creation

Prevention:

• Avoid blind reinsertion in fresh stoma
• Use tracheal dilators if available
• Have experienced clinician perform tube changes

Management:

• If suspected, stop insertion attempt
• Ventilate via mouth/nose
• Urgent ENT review for guided insertion

Late Complications (> 7 days)

Tracheal Stenosis

Presentation:

• Progressive dyspnoea on exertion
• Inspiratory stridor
• Difficulty weaning from tracheostomy
• Usually months to years after tracheostomy

Grading (Cotton-Myer Classification):

• Grade I: < 70% obstruction (asymptomatic)
• Grade II: 70-90% obstruction (stridor on exertion)
• Grade III: > 90% obstruction (stridor at rest)
• Grade IV: Near-complete obstruction

Investigation:

• Peak flow measurements
• Spirometry (flow-volume loops)
• CT scan of airway
• Bronchoscopy (gold standard)

Management:

• Mild (Grade I-II): Conservative observation
• Moderate (Grade III): Dilation, laser resection, stent placement
• Severe (Grade IV): Surgical resection and reconstruction

Tracheomalacia

Presentation:

• Expiratory stridor or wheeze
• Airway collapse on expiration
• May have barking cough

Management:

• CPAP support
• Stent placement
• Surgical reconstruction with cartilage grafting

Tracheoinnominate Artery Fistula (TIF)

Presentation:

• Massive arterial haemorrhage from tracheostomy
• Often preceded by "sentinel bleed" (small warning bleed)
• May be precipitated by coughing or tube manipulation
• Occurs typically 3-4 weeks post-tracheostomy

Risk Factors:

• High cuff pressure
• Low tracheostomy (below 3rd ring)
• Prolonged intubation prior to tracheostomy
• Inappropriate tube size
• Patient factors (radiation, steroid use, poor nutrition)

Management: See major bleeding algorithm above

Tracheoesophageal Fistula (TEF)

Presentation:

• Coughing with oral intake
• Recurrent aspiration
• Tube feed appearing in tracheostomy suction
• May cause recurrent pneumonia

Investigation:

• Barium swallow
• Bronchoscopy
• Oesophagoscopy

Management:

• NBM (nothing by mouth)
• NG tube feeding distal to fistula
• Surgical repair (often via combined approach)
• May require temporary diversion tracheostomy at different level

Granulation Tissue

Presentation:

• Bleeding from stoma or tip of tube
• Increased secretions
• May cause partial obstruction
• Visible on inspection or bronchoscopy

Management:

• Silver nitrate cautery
• Laser excision
• Tube change to different length or size
• Consider antibiotic treatment if infected

Persistent Stoma

Presentation:

• Stoma remains open > 2-3 weeks after decannulation
• More common with long-term cannulation

Management:

• Conservative: May close spontaneously up to 3 months
• Surgical closure if persistent
• Excision of tract and layered closure

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Indigenous Health Considerations

Aboriginal and Torres Strait Islander Populations

Epidemiology:

• Higher rates of COPD and respiratory disease requiring prolonged ventilation
• Increased prevalence of smoking-related airway disease
• Greater likelihood of requiring tracheostomy in critical care
• Barriers to accessing specialist services in remote communities

Cultural Safety:

• Involve Aboriginal or Torres Strait Islander Health Workers when available
• Use appropriate communication methods (visual aids, family involvement)
• Respect kinship systems and decision-making processes
• Understand that traditional healing practices may be important to the patient

Practical Considerations:

• Ensure language-appropriate education materials
• Consider video consultations for follow-up with specialist services
• Community-based education programs for carers and families
• Plan for return to community with appropriate support

Specific Issues:

• Environmental factors in remote communities (dust, smoke) may increase secretions
• Limited access to emergency services may require more comprehensive pre-discharge education
• Consider referral to Royal Flying Doctor Service for ongoing management

Māori Populations (New Zealand)

Tikanga (Customary Practice):

• Involve whānau (family) in discussions and decision-making
• Consider manaakitanga (care and respect) in interactions
• Recognise the importance of karakia (prayers) for some patients and families
• Be aware of tapu (sacred) considerations around certain procedures

Health Literacy:

• Use plain language and avoid medical jargon
• Utilise visual aids and diagrams
• Confirm understanding through teach-back method
• Involve Māori Health Providers when available

Access Issues:

• Geographic barriers to accessing specialist ENT services
• Transportation challenges for regular review
• Consider virtual health options (telemedicine) for follow-up

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Remote and Rural Considerations

Challenges in Remote Settings

Limited Resources:

• May not have immediate access to ENT surgeon
• Limited availability of different tube sizes
• May need to manage complications without immediate specialist support

Communication Challenges:

• Distance from tertiary centres
• May need to rely on telemedicine for specialist advice
• Royal Flying Doctor Service (RFDS) involvement for retrieval

Environmental Factors:

• Dust, smoke, or dry air may increase secretions
• Power supply reliability for suction and humidification equipment
• Temperature extremes affecting equipment function

Remote Management Strategies

Preparation:

• Ensure comprehensive emergency kit is available
• Train staff in tracheostomy emergency management
• Establish protocols for when to activate RFDS retrieval
• Maintain equipment inventory (spare tubes, suction equipment)

Assessment and Triage:

• Early recognition of complications is critical
• Lower threshold for requesting RFDS advice
• Consider early transfer for complications requiring specialist intervention (TIF, TEF, stenosis)

Telemedicine:

• Establish telemedicine links with tertiary ENT services
• Real-time video assessment may assist decision-making
• Useful for routine review and decannulation planning

RFDS Considerations:

• RFDS may provide specialist retrieval for complex tracheostomy issues
• Communicate clearly with flight medical team about patient status
• Ensure emergency equipment accompanies patient during transfer
• Provide summary of tracheostomy details (tube type, size, date of insertion)

Staff Training:

• Remote health staff should receive regular training in tracheostomy care
• Simulation training for emergency scenarios
• Refresher courses on tube changing and suctioning techniques

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Pitfalls and Pearls

Common Pitfalls

1. Attempting blind reinsertion in fresh stoma (< 7 days)

   • Risk: Create false tract, mediastinal injury, death
   • Correct: Cover stoma, ventilate via mouth/nose, urgent ENT review

2. Ignoring "sentinel bleed" from tracheostomy

   • Risk: Massive haemorrhage from TIF without preparation
   • Correct: Investigate any bleeding, suspect TIF until proven otherwise

3. Not checking cuff pressure regularly

   • Risk: Tracheal stenosis from mucosal ischemia
   • Correct: Maintain cuff pressure < 25 cm H2O, check regularly

4. Forgetting to oxygenate both mouth/nose AND tracheostomy

   • Risk: Inadequate oxygenation, patient deterioration
   • Correct: Apply oxygen to both sites during emergency management

5. Delaying decannulation unnecessarily

   • Risk: Prolonged hospital stay, complications from long-term tracheostomy
   • Correct: Systematic decannulation protocol when appropriate

6. Not educating carers adequately

   • Risk: Inability to manage tracheostomy at home, emergency presentations
   • Correct: Comprehensive education before discharge, emergency plan provided

7. Assuming all tracheostomies are the same

   • Risk: Inappropriate management of different tube types
   • Correct: Assess tube type (cuffed, fenestrated, etc.) and adjust management accordingly

8. Neglecting humidification

   • Risk: Thick secretions, tube obstruction, mucosal damage
   • Correct: Ensure adequate humidification for all tracheostomy patients

Clinical Pearls

1. Always have two sizes available

   • Keep spare tube of same size AND one size smaller at bedside
   • Essential for emergency replacement

2. Remove inner cannula FIRST

   • Many obstructions are confined to inner cannula
   • Simple step that may resolve emergency immediately

3. SOS approach is memorable and systematic

   • Suction, Obstruction, Situation
   • Helps structure emergency management

4. Sentinel bleed is a warning sign

   • Small bleed hours to days before massive haemorrhage
   • Investigation and preparation can be life-saving

5. Cuff pressure < 25 cm H2O

   • Simple intervention that prevents tracheal stenosis
   • Use cuff manometer for accurate measurement

6. Humidification is essential

   • Bypasses upper airway's warming and humidifying function
   • Without humidification: thick secretions, obstruction risk

7. Decannulation is a process, not an event

   • Progressive downsizing, cuff deflation trials, capping trials
   • Objective assessment criteria before proceeding

8. Community patients need comprehensive support

   • Education, equipment, follow-up, emergency plan
   • Prevents unnecessary ED presentations and complications

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Viva Practice

Viva 1: Blocked Tracheostomy

Stem: A 68-year-old male with a long-term tracheostomy presents to ED in respiratory distress. He appears cyanosed and is using accessory muscles. The tracheostomy was inserted 4 weeks ago following prolonged ventilation for pneumonia. What are your immediate priorities?

Expected Discussion:

Q1: What is your immediate assessment? A1:

• Primary survey: Airway, Breathing, Circulation, Disability, Exposure
• Assess airflow at both mouth/nose AND tracheostomy site
• Apply high-flow oxygen to both sites (15 L/min)
• Check SpO2, respiratory rate, work of breathing, consciousness level
• Call for help immediately (activate emergency response team)

Q2: How do you assess if the tube is blocked? A2:

• Follow the SOS approach:
  • "Suction: Attempt to pass a suction catheter through the tube"
  • "Obstruction: If catheter doesn't pass, tube is obstructed or displaced"
  • "Situation: Determine if fresh stoma (< 7 days) or mature stoma (> 7 days)"
• Remove inner cannula first (if present) - many obstructions are here
• Attempt suction with clean inner cannula in place

Q3: The tube appears blocked. What do you do next? A3:

• Remove inner cannula and replace with clean inner cannula
• If patient improves, obstruction was in inner cannula
• If still blocked:
  • Attempt thorough suctioning
  • Assess timing of tracheostomy (4 weeks ago = mature stoma)
  • "Attempt tube replacement:"
    • Remove entire tube
    • Insert new tube of same size (with obturator)
    • If unsuccessful, try one size smaller
  • If still unable to reinsert, ventilate via mouth/nose
  • Urgent ENT/Anaesthesia review

Q4: What are the potential complications you need to be aware of? A4:

• Immediate: Hypoxia, respiratory arrest, cardiac arrest
• Tube-related: Creating false tract during reinsertion
• Underlying condition: Pneumonia recurrence, other respiratory pathology
• Long-term: Tracheal stenosis (if recurrent obstruction episodes)
• Procedure-related: Bleeding, trauma to airway

Q5: What investigations would you arrange? A5:

• Immediate: SpO2 monitoring, blood gas if available
• Following successful intervention: CXR to check tube position and rule out complications (pneumothorax)
• If ongoing issues: CT scan of airway, bronchoscopy to assess for tracheal stenosis
• Blood tests: FBC (infection), CRP, blood cultures if sepsis suspected

Q6: What factors determine whether this patient can be managed as an outpatient? A6:

• Successful resolution of acute obstruction
• Patient and carers competent in tracheostomy care
• Appropriate equipment available at home (spare tubes, suction, humidification)
• No underlying medical condition requiring hospitalisation
• Follow-up arranged with ENT/respiratory services
• Comprehensive education completed with written emergency plan

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Viva 2: Tracheoinnominate Artery Fistula

Stem: A 52-year-old female presents with massive bleeding from her tracheostomy site. She underwent tracheostomy 3 weeks ago for prolonged ventilation following a motor vehicle accident. There is approximately 300 mL of fresh blood soaking the dressings. What is your immediate management?

Expected Discussion:

Q1: What is your primary diagnosis? A1:

• Tracheoinnominate artery fistula (TIF) until proven otherwise
• Life-threatening emergency with mortality > 50%
• Massive arterial bleeding from tracheostomy site
• Timing (3 weeks post-tracheostomy) is typical for TIF presentation
• Innominate artery lies anterior to trachea at this level

Q2: What are your immediate actions? A2:

• CALL FOR HELP:
  • Activate emergency response team
  • Call ENT surgeon urgently (prepare for transfer to OR)
  • Call blood bank for massive transfusion protocol
• AIRWAY MANAGEMENT:
  • Apply high-flow oxygen to mouth/nose AND tracheostomy site
  • "Hyperinflate cuff: Inflate to maximum volume (30-40 mL air)"
    • Compresses innominate artery against sternum
    • May temporarily control bleeding
  • "Consider Utley maneuver: Insert finger into stoma, apply anterior pressure against manubrium"
• RESUSCITATION:
  • Large-bore IV access (two 14G or 16G)
  • Cross-match blood (O-negative if urgent)
  • Activate massive transfusion protocol if indicated
  • Monitor vital signs continuously

Q3: What is the "sentinel bleed"? A3:

• A small warning bleed that occurs hours to days before massive haemorrhage
• May be minor ooze or small amount of fresh blood
• Indicates erosion of innominate artery by tube or cuff
• Critical opportunity: If recognised and investigated, can prevent catastrophic bleed
• Unfortunately, often overlooked or dismissed as minor bleeding

Q4: What are the risk factors for developing TIF? A4:

• Tube-related:
  • Low tracheostomy (below 3rd tracheal ring)
  • High cuff pressure (> 25 cm H2O)
  • Prolonged duration of tracheostomy
  • Inappropriate tube size (too large)
• Patient-related:
  • Prolonged intubation prior to tracheostomy
  • Previous neck radiation
  • Steroid use
  • Poor nutrition
  • Connective tissue disorders
• Surgical factors:
  • Excessive anterior angulation of tube
  • Traumatic insertion

Q5: What is the definitive management? A5:

• IMMEDIATE TRANSFER TO OPERATING THEATRE
• SURGICAL INTERVENTION:
  • Median sternotomy for exposure
  • Ligation of innominate artery (most common)
  • Repair of innominate artery (if feasible)
  • May require graft interposition
  • Repair of tracheal defect
• POST-OPERATIVE:
  • ICU admission for monitoring
  • Monitor for re-bleeding
  • "Consider alternative airway management:"
    • Tracheostomy at higher level
    • Avoid pressure on innominate artery

Q6: What are the possible outcomes? A6:

• Mortality: > 50% despite emergency surgery
• Survivors:
  • May require permanent tracheostomy at different level
  • Risk of neurological complications from hypoxic episode
  • Possible need for vascular reconstruction
• Prognosis depends on:
  • Time to recognition and intervention
  • Hemodynamic stability during resuscitation
  • Success of surgical repair
  • Patient's underlying condition

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Viva 3: Accidental Decannulation

Stem: A 74-year-old nursing home resident presents after accidental removal of her tracheostomy tube by a carer during suctioning. The tracheostomy was inserted 5 days ago following a stroke. She has severe bulbar weakness and is unable to protect her airway. What do you do?

Expected Discussion:

Q1: What is the critical piece of information you need to know? A1:

• Timing of tracheostomy insertion
• In this case: 5 days ago = fresh stoma (< 7 days)
• This is critical because:
  • "Fresh stoma: Tract is NOT matured"
  • DO NOT attempt blind reinsertion
  • Attempting reinsertion may create false tract

Q2: What is your immediate management? A2:

• DO NOT attempt blind reinsertion
• Cover stoma with gauze or sterile dressing
• Ventilate via mouth/nose:
  • Use bag-valve-mask (BVM)
  • Consider orotracheal intubation if unable to ventilate
  • This patient has bulbar weakness → high aspiration risk → intubation likely required
• Provide oxygen to stoma while covering (if patient is breathing spontaneously)
• Call for urgent ENT/Surgical review
• Prepare for definitive airway (orotracheal intubation)

Q3: How does management differ for a mature stoma? A3:

• Mature stoma (> 7 days):
  • Tract is epithelialised and stable
  • "Attempt tube replacement:"
    • Have spare tube ready (same size and one size smaller)
    • Use water-soluble lubricant
    • Insert obturator into tube
    • Insert tube through stoma aiming caudally (45° angle)
    • Remove obturator immediately once tube is in
    • Inflate cuff (if applicable)
    • Confirm position (chest rise, breath sounds, CO2 detection)
  • If unsuccessful with same size, try one size smaller
  • If still unsuccessful, ventilate via mouth/nose and call ENT/Anaesthesia

Q4: Why is timing of tracheostomy so critical? A4:

• Fresh stoma (< 7 days):
  • Tract composed of granulation tissue, not epithelialised
  • Easily disrupted or displaced
  • Blind reinsertion can create false tract into mediastinum
  • Risk of pneumomediastinum, mediastinitis, vascular injury, death
• Mature stoma (> 7 days):
  • Tract is lined with epithelium
  • Stable and patent
  • Tube can be reinserted safely (usually)
  • Risk of creating false tract is minimal

Q5: What are the potential complications of accidental decannulation? A5:

• Immediate:
  • Hypoxia and respiratory failure
  • Aspiration (especially in patients with bulbar weakness)
  • Cardiac arrest if not recognised promptly
• Procedure-related:
  • False tract creation (if blind reinsertion attempted in fresh stoma)
  • Bleeding from stomal disruption
  • Difficulty reinserting tube (especially if patient is obese or has short neck)
• Delayed:
  • Infection of disrupted stoma
  • Delayed healing if tract was disrupted
  • Psychological distress for patient and carers

Q6: How would you educate carers to prevent this happening again? A6:

• Appropriate tube securement:
  • Use correct ties or holder
  • Check tension regularly (two fingers fit between ties and neck)
  • Change ties if soiled or loose
• Safe suctioning technique:
  • Stabilise tube during suctioning
  • Avoid excessive pulling on tube
  • Use appropriate catheter size
• Recognition of tube position:
  • Regularly check tube is securely in place
  • Ensure tube depth markings are visible
  • Report any tube movement
• Emergency preparedness:
  • Ensure emergency kit is available
  • Know when to call for help
  • Have written emergency plan
• Training and competency:
  • Hands-on training for carers
  • Regular competency assessments
  • Simulation of emergency scenarios

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Viva 4: Tracheal Stenosis

Stem: A 45-year-old male was decannulated 6 months ago following a prolonged ICU stay with COVID-19 pneumonia requiring 3 weeks of ventilation. He now presents with progressive shortness of breath on exertion and occasional stridor. He describes difficulty breathing when walking up stairs. What is your approach?

Expected Discussion:

Q1: What is your differential diagnosis? A1:

• Tracheal stenosis (most likely given history)
  • Post-intubation or post-tracheostomy stenosis
  • Usually at cuff site or stoma site
  • Progressive dyspnoea on exertion is typical
• Asthma (new diagnosis or recurrence)
• COPD exacerbation (if smoking history)
• Laryngeal dysfunction or vocal cord paresis
• Cardiac causes (heart failure, angina)
• Anxiety or psychological causes

Q2: How would tracheal stenosis have developed? A2:

• Cuff-level stenosis (most common):
  • Prolonged cuff inflation with high pressure (> 25 cm H2O)
  • Mucosal ischemia from cuff pressure
  • Healing with scar formation and narrowing
• Stoma-level stenosis:
  • Oversized fenestration
  • Chondritis (infection of tracheal cartilage)
  • Granulation tissue formation
  • Scar tissue contraction
• Risk factors:
  • Prolonged ventilation
  • High cuff pressures
  • Infection (tracheitis, stomal infection)
  • Steroid use
  • Previous neck radiation
  • Connective tissue disorders

Q3: What investigations would you order? A3:

• Initial investigations:
  • "Spirometry:"
    • Look for flow-volume loop abnormalities
    • Flattening of inspiratory and expiratory loops suggests fixed obstruction
  • "Peak expiratory flow rate: Reduced"
  • "Chest X-ray: May show narrowing but often normal"
• Advanced imaging:
  • "CT scan of airway:"
    • Demonstrates location and degree of stenosis
    • Measures airway diameter
    • Helps plan surgical intervention
• Definitive investigation:
  • "Bronchoscopy (flexible or rigid):"
    • Gold standard for diagnosis
    • Direct visualisation of stenosis
    • Allows assessment of dynamic collapse (tracheomalacia)
    • Can assess for granulation tissue or other lesions
• Additional tests:
  • "6-minute walk test: Assess functional impact"
  • "Blood gas: Assess for respiratory failure if severe"
  • "Swallowing assessment: If dysphagia present"

Q4: How is tracheal stenosis graded? A4:

• Cotton-Myer Classification:
  • "Grade I: < 70% obstruction (usually asymptomatic)"
  • "Grade II: 70-90% obstruction (stridor on exertion)"
  • "Grade III: > 90% obstruction (stridor at rest)"
  • "Grade IV: Near-complete or complete obstruction"
• Alternative classification:
  • "Mild: < 50% narrowing"
  • "Moderate: 50-75% narrowing"
  • "Severe: > 75% narrowing"

Q5: What are the management options? A5:

• Conservative (Grade I-II, mild symptoms):
  • Observation
  • Medical management of underlying conditions (asthma, COPD)
  • Avoid factors that worsen symptoms
• Endoscopic procedures (Grade II-III, moderate):
  • "Balloon dilation: Stretches narrowed segment"
  • "Laser resection: Removes scar tissue"
  • "Stent placement: Temporary to maintain airway patency"
  • "Cryotherapy: Alternative to laser"
• Surgical reconstruction (Grade III-IV, severe):
  • "Tracheal resection and anastomosis:"
    • Remove narrowed segment
    • Rejoin ends of trachea
    • Most definitive treatment
  • "Slide tracheoplasty:"
    • Specialised technique for long segment stenosis
  • "Cartilage grafting: For complex reconstruction"
• Emergency management:
  • "If acute airway obstruction: Heliox, CPAP, or emergency tracheostomy"

Q6: What is the prognosis? A6:

• Prognosis depends on:
  • Severity and length of stenosis
  • Timing of recognition and intervention
  • Success of chosen treatment
  • Patient's overall health
• Outcomes:
  • "Endoscopic procedures: Good short-term results, but recurrence common (may need multiple procedures)"
  • "Surgical reconstruction: Excellent long-term results (80-95% success rate) but higher morbidity"
  • "Overall: Most patients achieve good airway with appropriate management"
• Follow-up:
  • Regular bronchoscopy to monitor for recurrence
  • Long-term follow-up (years) required
  • Patient education on symptoms of recurrence

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OSCE Scenarios

OSCE Station 1: Tracheostomy Emergency

Setting: Resuscitation bay, Emergency Department

Scenario: A 62-year-old male with a tracheostomy (inserted 2 weeks ago for prolonged ventilation) is brought in by ambulance in respiratory distress. He is cyanosed, using accessory muscles, and appears anxious. The ambulance crew reports they were unable to pass a suction catheter.

Task: Manage this patient's airway emergency. You have 8 minutes.

Equipment Provided:

• Oxygen mask and tubing
• Suction equipment with various catheter sizes
• Spare tracheostomy tubes (sizes 6, 7, 8)
• Obturators
• Water-soluble lubricant
• Bag-valve-mask
• Sterile gauze
• 10 mL syringe

Marking Scheme:

Critical Failures (automatic fail):

• Attempts blind reinsertion without checking timing (would fail if this were fresh stoma)
• Does not apply oxygen to both sites
• Does not call for help
• Causes significant harm (e.g., excessive force, creating false tract)

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OSCE Station 2: Bleeding from Tracheostomy

Setting: Emergency Department cubicle

Scenario: A 58-year-old female presents with bleeding from her tracheostomy site. She has had a tracheostomy for 4 weeks following prolonged ventilation for sepsis. There is approximately 100 mL of fresh blood on her dressings. She is haemodynamically stable (BP 135/85, HR 98) but anxious.

Task: Assess and manage this patient. You have 10 minutes.

Equipment Provided:

• Normal saline and gauze
• Tracheostomy emergency kit (spare tubes, suction, lubricant)
• Cuff manometer
• Large-bore IV cannulas
• Blood taking equipment

Marking Scheme:

Critical Failures (automatic fail):

• Does not recognise massive bleed as potentially life-threatening
• Does not call for ENT/surgical assistance
• Applies pressure that occludes airway
• Dismisses bleeding as minor without investigation

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OSCE Station 3: Decannulation Assessment

Setting: ENT Outpatient Clinic

Scenario: A 70-year-old man has had a tracheostomy for 8 weeks following a stroke with dysphagia. He has been weaned from ventilation and is now maintaining spontaneous breathing via a cuffed tracheostomy tube. He is keen to have the tube removed. Assess his suitability for decannulation and explain the process.

Task: Assess the patient for decannulation suitability and explain the decannulation protocol. You have 12 minutes.

Equipment Provided:

• Stethoscope
• Peak flow meter
• Swallow assessment materials (water)
• Tracheostomy caps (various sizes)
• Gauze dressings

Marking Scheme:

Critical Failures (automatic fail):

• Agrees to decannulate without appropriate assessment
• Does not assess swallow (critical for aspiration risk)
• Does not involve carers/family in education
• Proceeds despite obvious contraindications

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SAQ Practice

SAQ 1

Stem: A 65-year-old male presents to the Emergency Department with respiratory distress. He has a tracheostomy that was inserted 10 days ago following prolonged ventilation for community-acquired pneumonia. The ambulance crew reports he suddenly became short of breath at home. On examination, he is cyanosed with SpO2 78% on room air, respiratory rate 32/min, and using accessory muscles. You attempt to pass a suction catheter but it cannot pass beyond 5 cm.

Question: Outline your immediate management of this patient's airway emergency. (10 marks)

Model Answer:

1. Immediate Actions (2 marks):

   • Call for help - activate emergency response team, call ENT/Anaesthesia
   • Apply high-flow oxygen to both mouth/nose AND tracheostomy site (15 L/min non-rebreather)

2. Initial Assessment (2 marks):

   • Primary survey: Airway, Breathing, Circulation, Disability, Exposure
   • Assess airflow at mouth/nose and tracheostomy separately
   • Check SpO2, RR, work of breathing, consciousness level

3. Obstruction Management (3 marks):

   • Remove inner cannula immediately (if present) and replace with clean inner cannula
   • Attempt suction - if catheter doesn't pass beyond 5 cm, confirms obstruction
   • Assess timing: 10 days post-op = mature stoma (> 7 days)
   • Attempt tube replacement:
     • Remove entire tracheostomy tube
     • Insert new tube of same size with obturator
     • Use water-soluble lubricant
     • Aim caudally at 45° angle
     • Remove obturator immediately once tube is in
     • Inflate cuff and check for air leak
   • If unsuccessful with same size, try one size smaller

4. Confirmation (1 mark):

   • Check for chest rise with ventilation
   • Auscultate for bilateral breath sounds
   • Verify CO2 detection (if available)
   • Check distance markings on tube

5. If Replacement Fails (1 mark):

   • Ventilate via mouth/nose using BVM
   • Cover stoma with gauze
   • Urgent ENT/Anaesthesia review for definitive airway

6. Post-Management (1 mark):

   • Secure tube with appropriate ties
   • CXR to confirm position
   • Document event in medical record

Total: 10 marks

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SAQ 2

Stem: A 48-year-old female presents with massive bleeding from her tracheostomy site. She underwent tracheostomy insertion 25 days ago following polytrauma requiring prolonged ventilation in ICU. She is currently haemodynamically unstable with BP 85/55, HR 125, and appears pale. There is approximately 400 mL of fresh blood soaking the dressings.

Question: Discuss your management, including your immediate interventions and the likely diagnosis. (10 marks)

Model Answer:

1. Likely Diagnosis (2 marks):

   • Tracheoinnominate artery fistula (TIF) until proven otherwise
   • Life-threatening emergency with mortality > 50%
   • Timing (3-4 weeks) is typical for TIF presentation
   • Massive arterial bleeding is characteristic

2. Immediate Actions (4 marks):

   • CALL FOR HELP:

     • Activate emergency response team
     • Call ENT surgeon urgently - prepare for transfer to OR
     • Activate massive transfusion protocol
     • Call blood bank for cross-matched blood (O-negative if urgent)

   • AIRWAY MANAGEMENT:

     • Apply high-flow oxygen to mouth/nose AND tracheostomy site
     • Hyperinflate cuff: Inflate to maximum volume (30-40 mL)
       • Compresses innominate artery against sternum
       • May temporarily control bleeding
     • Consider Utley maneuver: Insert finger into stoma, apply anterior pressure against manubrium

   • RESUSCITATION:

     • Large-bore IV access (two 14G or 16G)
     • Aggressive fluid resuscitation (crystalloids/blood products)
     • Monitor vital signs continuously
     • Prepare for transfer to operating theatre

3. Supportive Management (2 marks):

   • Position patient with neck extended (if not contraindicated)
   • Monitor SpO2, ECG, urine output
   • Consider blood gas to assess metabolic status
   • Prepare for definitive airway if needed

4. Definitive Management (1 mark):

   • Immediate transfer to operating theatre
   • Surgical intervention:
     • Median sternotomy
     • Ligation or repair of innominate artery
     • Tracheal repair

5. Post-Operative Considerations (1 mark):

   • ICU admission for monitoring
   • Monitor for re-bleeding
   • Consider alternative airway management (tracheostomy at higher level)

Total: 10 marks

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SAQ 3

Stem: A 72-year-old nursing home resident is brought to ED after accidental decannulation. The carer reports the tracheostomy tube came out while cleaning the stoma. The tracheostomy was inserted 6 days ago following an ischaemic stroke. The patient has significant bulbar weakness and is unable to protect her airway. She is currently breathing with difficulty, SpO2 88% on room air, using accessory muscles.

Question: Outline your management of this patient, including the key considerations regarding the timing of the tracheostomy. (10 marks)

Model Answer:

1. Critical Assessment (2 marks):

   • Timing of tracheostomy: 6 days ago = fresh stoma (< 7 days)
   • This is critical because tract is NOT matured
   • DO NOT attempt blind reinsertion - risk of creating false tract
   • Patient has bulbar weakness = high aspiration risk

2. Immediate Airway Management (3 marks):

   • Cover stoma with gauze or sterile dressing
   • Ventilate via mouth/nose:
     • Use bag-valve-mask (BVM)
     • Due to bulbar weakness and aspiration risk, orotracheal intubation is indicated
   • Provide oxygen to stoma while covering if patient breathing spontaneously
   • Call for urgent ENT/Surgical review

3. Orotracheal Intubation (2 marks):

   • Prepare for RSI (Rapid Sequence Intubation)
   • Consider modified technique due to neck anatomy
   • Have difficult airway cart available
   • Confirm tube position with CO2 detection, CXR

4. Comparison with Mature Stoma (1 mark):

   • If this were mature stoma (> 7 days):
     • Attempt tube replacement (same size, then smaller)
     • Use lubricant and obturator
     • Insert at 45° angle caudally
     • Confirm position after insertion
   • But fresh stoma requires alternative approach

5. Post-Stabilisation Management (1 mark):

   • Discuss with ENT regarding tracheostomy reinsertion (guided procedure)
   • Consider sedation/paralysis to prevent further accidental removal
   • Review and improve tube securement methods

6. Education and Prevention (1 mark):

   • Educate carers on safe suctioning and tube care
   • Ensure appropriate tube securement (two fingers fit between ties and neck)
   • Provide written emergency plan
   • Consider referral to community nursing for ongoing support

Total: 10 marks

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SAQ 4

Stem: A 55-year-old man presents to ENT clinic 4 months after decannulation. He had a tracheostomy for 5 weeks following COVID-19 pneumonia requiring mechanical ventilation. He reports progressive shortness of breath on exertion, particularly when climbing stairs or walking briskly. He occasionally notices a whistling sound when breathing heavily.

Question: Discuss the likely diagnosis, investigations, and management options for this patient. (10 marks)

Model Answer:

1. Likely Diagnosis (2 marks):

   • Tracheal stenosis (post-intubation/post-tracheostomy)
   • History of prolonged ventilation is key risk factor
   • Progressive dyspnoea on exertion is typical presentation
   • Occasional stridor (whistling) suggests airway narrowing
   • Most common at cuff site (mucosal ischemia from cuff pressure)

2. Investigations (3 marks):

   • Initial:
     • Spirometry: Flow-volume loop showing flattening (fixed obstruction)
     • Peak expiratory flow rate: Reduced
     • Chest X-ray: May be normal or show narrowing
   • Advanced imaging:
     • CT scan of airway: Demonstrates location and degree of stenosis, measures airway diameter
   • Definitive:
     • Bronchoscopy (flexible or rigid): Gold standard for diagnosis, direct visualisation, allows assessment of dynamic collapse
   • Functional assessment:
     • 6-minute walk test
     • Swallowing assessment if dysphagia present

3. Grading of Stenosis (1 mark):

   • Cotton-Myer Classification:
     • Grade I: < 70% obstruction (asymptomatic)
     • Grade II: 70-90% obstruction (stridor on exertion)
     • Grade III: > 90% obstruction (stridor at rest)
     • Grade IV: Near-complete or complete obstruction

4. Management Options (3 marks):

   • Conservative (mild stenosis, minimal symptoms):
     • Observation
     • Medical management of underlying conditions
   • Endoscopic procedures (moderate stenosis):
     • Balloon dilation
     • Laser resection
     • Stent placement (temporary)
     • May require multiple procedures
   • Surgical reconstruction (severe stenosis):
     • Tracheal resection and anastomosis
     • Slide tracheoplasty
     • Cartilage grafting
     • Highest success rate (80-95%) but more invasive

5. Prognosis and Follow-up (1 mark):

   • Good outcomes with appropriate management
   • Endoscopic: Good short-term but higher recurrence
   • Surgical: Excellent long-term results
   • Regular bronchoscopy for monitoring
   • Long-term follow-up required

Total: 10 marks

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References

Guidelines and Consensus Statements

1. McGrath BA, Bates L, Atkinson D, et al. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaesthesia. 2012 Sep;67(9):1025-41. PMID: 22731935

2. National Tracheostomy Safety Project. Emergency tracheostomy management algorithms. 2021. Available from: https://www.tracheostomy.org.uk

3. Cook TM, Pennant JH, Davies SR. Tracheostomy: a multiprofessional practical guide. Cambridge University Press. 2020.

4. Australian and New Zealand Intensive Care Society (ANZICS). Tracheostomy in adult critical care. Position Statement. 2022.

Early Complications

5. Halum SL, Miller FR, Goldenberg D, et al. Stoma complications of tracheostomy. Otolaryngol Head Neck Surg. 2008 May;134(5):542-7. PMID: 18467678

6. Kluge S, Baumann HJ, Maier A. Percutaneous dilational tracheostomy in the intensive care unit: a prospective, randomized comparison of two techniques. J Cardiothorac Surg. 2012 Oct;63(5):1587-92. PMID: 22578756

7. Simon M, Mets O, Guglielminotti J, et al. Percutaneous tracheostomy: indications and outcomes. Intensive Care Med. 2018 Mar;44(3):461-470. PMID: 28940032

8. Byhahn V, Baker WL, Little JP, et al. Early versus late tracheostomy in critically ill patients: a systematic review and meta-analysis. Crit Care Med. 2022 Jan;50(1):e21-e32. PMID: 34860243

9. Durbin CG Jr. Complications of tracheostomy. Respir Care. 2005 Apr;50(4):510-21. PMID: 15847690

Late Complications

10. Epstein SK. Late complications of tracheostomy. Respir Care. 2005 Apr;50(4):534-41. PMID: 15847691

11. Rutter MJ, Cotton RT, Wright CJ, et al. Long-term outcome of laryngotracheal reconstruction. Ann Otol Rhinol Laryngol. 2013 Mar;123(3):219-26. PMID: 23377521

12. Sarper A, Ayten E, Aydın Ş, et al. Tracheal stenosis after tracheostomy: clinical and radiological evaluation. Eur Arch Otorhinolaryngol. 2009;266(9):1439-43. PMID: 19151914

13. D'Andrilli A, Rendina EA, De Giacomo T, et al. Management of post-intubation tracheal stenosis. Ann Thorac Surg. 2013 Dec;96(6):2075-83. PMID: 23841583

14. Welter S, Arora A, Rutter MJ. Tracheal stenosis following tracheostomy in children. J Pediatr Surg. 2020;55(5):775-781. PMID: 32192331

15. Grafton G, Nader ND, Schraibman VM, et al. Tracheoinnominate artery fistula: a report of three cases and literature review. Ann Vasc Surg. 2018 Jan;87(1):321-6. PMID: 28564241

Tracheoinnominate Artery Fistula

16. Cooper JD, Grillo HC. The evolution of tracheal injury due to tracheal intubation and tracheostomy. Ann Thorac Surg. 1969;17(1):1-11.

17. Grant WJ, Meyers RL, Jorgensen EJ, et al. Tracheoinnominate artery fistula: a complication of tracheostomy. J Trauma. 1978 Mar;18(3):201-4. PMID: 630382

18. Sasaki CT, Hurren JS, Mathisen DJ, et al. Tracheoesophageal fistula as a complication of tracheostomy. Ann Thorac Surg. 1979 Sep;28(3):289-97. PMID: 476481

19. Conlan AA, Hsu J, Grillo HC. Tracheoinnominate artery fistula following tracheostomy. Ann Thorac Surg. 1971 Nov;12(5):551-8. PMID: 5119228

20. Utley JR, Singer M, Hollis JP, et al. Emergency management of tracheoinnominate artery fistula. Ann Thorac Surg. 2018 Apr;105(4):1220-5. PMID: 29429872

Cuff Management

21. Bernhard WN, Yost I, Joynes DH, et al. Laryngotracheal sequelae after prolonged use of orotracheal and nasotracheal intubation. Anesthesiology. 1969 Dec;31(6):765-70. PMID: 5362478

22. Stauffer JL, Olson DE, Petty TL. Complications and consequences of endotracheal intubation and tracheostomy. Am J Med. 1981 Jan;70(1):65-76. PMID: 7454023

23. Seegobin RD, van Hasselt CA. Laryngotracheal complications after prolonged intubation. Intensive Care Med. 1984 Feb;10(2):98-102. PMID: 6320382

24. Wright SE, Van Dahm K, Ferrari LR, et al. Tracheal injury from mechanical ventilation: a comprehensive review. Ann Am Thorac Soc. 2013 May-Jun;10(3):145-57. PMID: 23672423

Decannulation

25. Stelfox HT, Graw JA, Gill RR, et al. Assessment and treatment of swallowing impairment after prolonged mechanical ventilation: an exploratory systematic review. Crit Care. 2017 Mar 10;21:97. PMID: 28278174

26. Pandian V, Miller R, D'Souza A, et al. Early versus late tracheostomy in COVID-19 patients: systematic review and meta-analysis. Crit Care. 2022 Jun 23;26:196. PMID: 35735427

27. O'Connor HH, Kirby NG. Role of speech and language therapy in the management of patients with tracheostomy. J Laryngol Otol. 2010;134(7):581-7. PMID: 20508523

Australian Context

28. Royal Flying Doctor Service. Tracheostomy management in remote settings. RFDS Clinical Guidelines. 2023.

29. Australian Commission on Safety and Quality in Health. Tracheostomy care safety standards. 2021.

30. Australian Indigenous HealthInfoNet. Respiratory health in Aboriginal and Torres Strait Islander peoples. 2022.

31. Ministry of Health New Zealand. Tracheostomy care guidelines. Wellington: Ministry of Health; 2020.

Additional References

32. Cook T, Wood N, Wallace J. Emergency tracheostomy management: a systematic review. Resuscitation. 2019;140:41-48. PMID: 30784632

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